• military
• austere
• surgical
• research
• academia

The medical care of those injured during conflict has measurably improved over the last 50 years.1 Within recent UN-mandated conflicts in Iraq and Afghanistan, the early adoption of research-driven innovations in the delivery of trauma care led to year-on-year improvements in survival rates from combat-related injury. The severity of injuries produced an appetite for risk in the search for life and limb-saving interventions and a rapidly reactive logistics chain facilitated the delivery of new solutions. Towards the end of the UK’s contribution to North Atlantic Treaty Organisation (NATO)-led operations in Afghanistan, British servicemen and women were likely to survive injuries almost twice as severe as those survivable at the start.2

The early care of those injured in such conflicts is delivered in complex, internationally dispersed and multinationally delivered military trauma systems. On arrival in the UK, treatment is continued within the National Health Service, principally at the Queen Elizabeth Hospital, Birmingham, before being returned to military rehabilitation services. Many of the lessons captured and learnt from these conflicts have been inculcated into civilian trauma practice in the UK, the use of massive blood transfusion protocols in the fluid resuscitation of bleeding patients and the adoption of surgical approaches to restore physiology rather than anatomy being but two examples. Such paradigms have contributed to measurable and significant improvements in survival from trauma in the UK.3 The closure of British military hospitals in the 1990s and the subsequent embedding of military medical personnel within NHS trusts facilitated this exchange of knowledge and has since permitted easy military/civilian collaboration when domestic terrorist incidents such as the 2017 Manchester Arena bombing have challenged NHS trauma systems.4 5

At the forefront of capability development have been medical, nursing and allied health professionals of the Royal Navy, the Army and the Royal Air Force. Alongside developing and maintaining General Medical Council-defined or Nursing and Midwifery Council-defined specialist skill sets to deliver civilian care within the UK, full time and reserve personnel from all three services are required to ensure competence in the delivery of military medical care in austere and challenging environments ranging from the deserts of the Middle East to the tropical wetlands of South Sudan. For doctors, comprehensive predeployment training and simulation tailored to the mission builds on military-specific skills and experience gained during time served at sea or on land as a General Duties Medical Officer.

Within the Armed Forces of the UK, the Defence Medical Services stand out in the support afforded to research and innovation to drive and enable the continual development of capability for operations. This has long been the case, with the establishment of Regius chairs of Military Surgery in Edinburgh and in Dublin during the reign of George III, driven by the requirement to train surgeons to a standard sufficient to treat the injured of the Peninsula War. Among the eight current academic departments, the chairs of Surgery and of Medicine have been continually appointed since their establishment in 1860, very shortly after the end of Crimean War.

The academic departments are, by their nature, very outward facing. By assisting UK Government, NHS, Royal Colleges, charities and global organisations such as the WHO, we inform policy and the global research agenda. Through international academic congresses and the exchange of researchers, we develop global partnerships. The collaboration with the Department for International Development in rapidly tackling the 2014 Ebola crisis in Sierra Leone is a notable example.

Underpinning this agile and flexible delivery of military medical capability, its continual development is carried out through discovery science and clinical research, through evidence synthesis and through innovation in service design. This development is delivered in part by internal medical research effort in directly funded and resourced programmes that answer our questions, while at the same time developing our brightest people in scholarship and in critical and divergent thinking. This internal research effort, however, is very small, accessing only 1% of Defence’s R&D budget. Of necessity, it is focused on niche areas such as blast physiology and chemical and biological defence. We access additional research capacity and capability by partnering with academic centres of excellence at home and abroad in collaborative programmes of palpable military benefit, resourced by charitable and non-MoD research funds currently totalling over £25M. At the time of writing, a total of 39 doctorates (29 PhD, 10 MD) are being carried out by serving medical officers, regular and reserve, at 14 centres of excellence across the UK and USA. During 2017, serving medical and nursing staff published 310 peer-reviewed articles, in journals reporting a median JCR Journal Impact Factor score of 2.19 (IQR 1.35–3.40). Two hundred and sixty-six conference presentations, podium and poster, national and international, were delivered.

Data-driven programmes of research are spread across the broad scope of operational and occupational clinical delivery,6 7 focused by Front Line Command priorities without being over-reactive, while at the same time retaining the organisational agility to respond rapidly to new threats. A renewed focus on the prevention, detection and treatment of training injury did not prevent a suite of research being rapidly instigated when a requirement appeared to deploy in support of UN peacekeeping in South Sudan. Duplication of effort is avoided by coordinating with our principal allies in NATO and beyond.

It is superficially attractive to exact a ‘peace dividend’ when not fighting, by reducing the support to military medical services and to their research programmes. To some extent this is inevitable, as the immediate imperative to innovate and the appetite for risk fall away. Invariably, however, this leads to a dip in capability at the start of the next conflict, paid for in lives lost as denuded military medical services are forced to rapidly readapt. While the exact nature of the next conflict can never be known,8 some factors remain constant. Small-scale threats that grasp news headlines cannot distract us from the constant that is the risk of large-scale peer-on-peer conflict, with a predominance of blast weapons and the dispersed nature in which end-to-end medical care is delivered. These are, however, only two examples.9 Maintaining an apposite baseline clinical skill set through relevant placement within NHS trusts,10 protecting a comprehensive logistics capability and promoting innovation through maintaining the depth and breadth of research activity will allow us to rapidly adapt when the character of that conflict is finally known.

The Defence Medical Services have captured many of the lessons from the provision of medical care during the most recent conflicts in Iraq and Afghanistan.11 12 Effort has now shifted away from the highly successful delivery of advanced trauma care during conflicts in Iraq and Afghanistan, and with a reduction in the numbers of uniformed Medical Officers, regular and reserve, we must be careful to avoid a ‘we can do trauma’ mindset. We must ensure, not only that those lessons are identified, but that they continue to be learnt. And we must strive continuously, through research and innovation to develop those services in waiting.